Stephen Soumerai, Sc'D' Professor Department of Ambulatory Care and Prevention Harvard Medical Schoo

1
Stephen Soumerai, Sc.D.ProfessorDepartment of
Ambulatory Care and PreventionHarvard Medical
School and Harvard Pilgrim Health Care
Designing Pharmacy Benefits to Improve Quality
and Contain Costs
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Evolution of Prescription Drug Benefits Designs

• Non-selective blunt tools can have unintended
  consequences, reduce clinical effectiveness, and
  increase total costs
• Caps on number of prescriptions
• Non-selective cost sharing
• Triplicate prescriptions

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Evolution of Prescription Drug Benefits Designs
(contd)

• Initial studies suggest that selective sharp
  tools that recognize relative effectiveness of
  drugs within a class can reduce inappropriate use
  and promote least-costly alternatives
• Reference pricing
• Tiered copayments
• Evidence-based preferred drug lists and
  formularies

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Unintended effects of non-selective cost-sharing
policies

• Reduces use of clinically important medicines
  (e.g., insulin, cardiac meds)
• Increases use of institutional services
• Nursing homes and hospitals (elderly)
• Day hospital and acute care (patients with
  schizophrenia.)
• May increase total health care costs
• Mental health cost offsets 17 x drug savings

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Time Series of Constant-Size Rxs per Continuously
Eligible Patient per Month among Multiple Drug
Recipients (N860) and Other Outpatients (N8002)
Source Soumerai et al, N Engl J Med 1987 317
550-6
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Cap-induced Changes in Essential Drugs
Droppers vs. Maintainers
4
3
2
STANDARD DOSES PER ELIGIBLE PERSON
1
BASELINE
3 DRUG CAP
1 COPAY
0
JUL 81
JUL 82
JUL 80
Source Soumerai et al, N Engl J Med 1994 331
650-5
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Effects of Prescription Cap on Nursing Home
Admissions
100
95
New Jersey
outside nursing home
90
New Hampshire
85
Baseline
Cap
After Cap
80
Source Soumerai et al, N Engl J Med 1991 325
1072-7
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Effect of Cap on Emergency Mental Health Services
Baseline
Cap
After Cap
Source Soumerai et al, N Engl J Med 1994 331
650-5
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Changes in Use of Essential Drugs With Change in
Cost Sharing
Source Tamblyn R et al, JAMA 2001 285 421-429
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Effect of a 0.50 per Rx Copayment on Medication
Use by Medicaid Recipients in South Carolina
Source Nelson, Reeder Dickson. Med Care Aug.
1984 p. 724
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Impact of Triplicate Prescription Program (TPP)
on Benzodiazepine (BZ) Prescribing
New Jersey
New York (-54.8)
Source Ross-Degnan et al (submitted)
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Impact of TPP on Use of BZ Indicated for Seizure
and Panic Disorder
Source Ross-Degnan et al (submitted)
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Reduction in BZ Use Among Patients with Seizure
Disorder
NJ Control Cohort
NY Study Cohort
Source Simoni-Wastila et al (submitted)